BMJ Open...fGSK Vaccines, Avenue Fleming 20, B-1300 Wavre, Belgium g GSK Vaccines, 2301 Renaissance Boulevard, RN 0220, P.O. Box 61540, King of Prussia, PA 19406-2772, USA

For peer review only

Immunogenicity and safety of early vaccination with two doses of a combined measles-mumps-rubella-varicella

vaccine in healthy Indian children from 9 months of age: a phase III, randomized, non-inferiority trial.

Journal: BMJ Open

Manuscript ID: bmjopen-2014-007202

Article Type: Research

Date Submitted by the Author: 14-Nov-2014

Complete List of Authors: Lalwani, Sanjay; Bharati Vidyapeeth Medical College, Pediatrics Chatterjee, Sukanta; Medical College Kolkata, Department of Pediatrics Balasubramanian, Sundaram; Kanchi Kamakoti Childs Trust Hospital, Bavdekar, Ashish; KEM Hospital, Mehta, Shailesh; GSK Pharmaceuticals, Datta, Sanjoy; GSK Vaccines, Povey, Michael; GSK Vaccines, Henry, Ouzama; GSK Vaccines,

<b>Primary Subject Heading</b>:

Paediatrics

Secondary Subject Heading: Paediatrics

Keywords: immunogenicity, India, measles-mumps-rubella-varicella vaccine, safety, vaccination schedule

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

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Title page

Title: Immunogenicity and safety of early vaccination with two doses of a combined measles-

mumps-rubella-varicella vaccine in healthy Indian children from 9 months of age: a phase III,

randomized, non-inferiority trial.

Authors: Sanjay Lalwani, Vice Principal, Professor and Head of Departmenta, Sukanta

Chatterjee, Professor of Pediatricsb, Sundaram Balasubramanian, Senior Pediatric Consultant

c,

Ashish Bavdekar, Associate Professor and Consultant Pediatric Gastroenterologistd, Shailesh

Mehta, Area Medical Leader (South Asia)e, Sanjoy Datta, VP, Clinical R&D and Medical Affairs

f,

Michael Povey, Biostatisticianf, Ouzama Nicholson, Clinical Research Development Lead

g

Affiliations: aDepartment of Pediatrics, Bharati Vidyapeeth Deemed University, Pune 411043,

India

bDepartment of Pediatrics, Medical College Kolkata, 88 College street, Kolkata 700073, India

cKanchi Kamakoti Childs Trust Hospital, 12-A, Nageswara Road, Nungambakkam, Chennai

600034, India

dDepartment of Pediatrics, KEM Hospital, 489 Rasta Peth, Sardar Moodliar Road, Pune 411011,

India

eGSK Pharmaceuticals Ltd., Dr. Annie Besant Road, Worli, Mumbai 400030, India

fGSK Vaccines, Avenue Fleming 20, B-1300 Wavre, Belgium

gGSK Vaccines, 2301 Renaissance Boulevard, RN 0220, P.O. Box 61540, King of Prussia, PA

19406-2772, USA

Correspondence to: Sanjay Lalwani

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Contact Details: +91 9822051716

Fax: +91 20 24364308

Email: [email protected]

Short title: Combined MMRV vaccine in Indian children

Abbreviations

ATP–according-to-protocol; CCID50–median cell culture infective dose; CI–confidence interval;

CRS–congenital rubella syndrome; ELISA–enzyme-linked immunosorbent assay; GMT–

geometric mean titer; IAP–Indian Academy of Pediatrics; mIU/mL–milli international unit per

milliliter; MMR–combined measles-mumps-rubella vaccine; MMR+V–coadministration of MMR

and V; MMRV–combined measles-mumps-rubella-varicella vaccine; pfu–plaque forming units;

SAE–serious adverse event; TVC–total vaccinated cohort; V–varicella; VZV–varicella zoster-

virus; WHO–World Health Organization

Keywords: immunogenicity, India, measles-mumps-rubella-varicella vaccine, safety, vaccination

schedule

Word count: 3521

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Abstract

Objective: This study (NCT00969436) compared the immunogenicity and safety of measles-

mumps-varicella (MMR) followed by MMR+varicella (V) vaccines to (1) two doses of combined

MMRV and (2) MMR followed by MMRV, in Indian children.

Design: Phase III, open, randomized, non-inferiority study.

Setting: Six tertiary care hospitals located in India.

Participants: Healthy subjects aged 9–10 months not previously vaccinated against/exposed to

measles, mumps, rubella and varicella or without a history of these diseases.

Interventions: Subjects were randomized (2:2:1) to receive two doses of either MMRV

(MMRV/MMRV group) or MMR followed by MMRV (MMR/MMRV group) or MMR followed by

MMR+V (MMR/MMR+V, control group) at 9 and 15 months of age. Antibody titers against

measles, mumps and rubella were measured using ELISA and against varicella using an

immunofluorescence assay.

Main outcome measures: To demonstrate non-inferiority of the two vaccination regimens vs.

the control in terms of seroconversion rates, defined as a group difference with a lower bound

of the 95% confidence interval >-10% for each antigen, 43-days post-dose-2. Parents/guardians

recorded solicited local and general symptoms for a 4-day and 43-day period after each vaccine

dose, respectively.

Results: The seroconversion rates post-dose-1 ranged from 87.5%–93.2% for measles, 83.3%–

86.1% for mumps and 98.7%–100% for rubella across the three vaccine groups. Seroconversion

rates post-dose-2 for measles, mumps and rubella was 100% and at least 95.8% for varicella

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across the three vaccine groups. Non-inferiority of MMRV/MMRV and MMR/MMRV to

MMR/MMR+V was achieved for all antigens, 43-days post-dose-2. The three vaccination

regimens were generally well-tolerated in terms of solicited local and general symptoms.

Conclusion: The immune responses elicited by the MMRV/MMRV and MMR/MMRV vaccination

regimens were non-inferior to those elicited by the MMR/MMR+V regimen for all antigens. The

three vaccination schedules also exhibited an acceptable safety profile in Indian children.

Abstract word count: 295/300

Trial registration: (NCT00969436)

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Article Summary

• Measles, mumps, rubella (MMR) and varicella are highly infectious vaccine-preventable

childhood diseases with high mortality rates in India.

• A combined MMR-varicella vaccine may potentially facilitate the control of all four

diseases which is as immunogenic as separate MMR and varicella vaccinations.

Strengths and limitations of this study

This Indian study provides first time data on:

• A combined MMRV vaccine in a highly endemic measles setting.

• MMRV administered to children at 9 months of age which aligns with the expanded

programme of immunization schedule of measles vaccine administered at this age.

• Prevaccination serostatus that offers epidemiological indicators on the early disease

burden for measles, mumps, rubella and varicella

This study had no limitations.

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Introduction

Measles, mumps, rubella and varicella are highly infectious vaccine-preventable childhood

diseases that continue to pose a significant public health problem in India and beyond.1-4

In

2010, global measles mortality was estimated at 139,000 (71,200–447,800) deaths, 47% of

which was estimated to have occurred in India.5 In 2011, large measles outbreaks were

reported in India (29,339 cases), Pakistan (4,386 cases), Nigeria (18,843 cases) and other

countries.6 Although measles elimination was declared in the United States in 2000, the

importation of the disease led to the highest number of cases in 2011 (220 cases) since 1996

while 159 cases were reported in 2013 by 16 states.7 In the European Union, the Dutch

authorites reported 1540 measles cases since May 2013 and in Germany, the reported number

of cases is nearly 10 times higher than the total cases in 2012.8 During the 2012–2013 outbreak,

there were over 2000 confirmed cases of measles in England and Wales.9 10

Thus, even

developed settings may be prone to epidemics if coverage wanes.

A dramatic decrease in the worldwide mumps disease burden has been observed since the

implementation of large-scale immunization in 1967.2 However, the true incidence in India is

difficult to ascertain due to limited baseline epidemiological data.11

Data from 2006 revealed that 82.2% children aged between 1 and 5 years, and 13.5% aged

between 10 and 15 years are susceptible to rubella in the Indian sub-continent.12

Although

congenital rubella syndrome (CRS) has been reported in most parts of India, no measures have

been undertaken to control this crippling disease and presently, reliable data on CRS in India is

limited.13

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Epidemiological data on varicella-zoster virus (VZV) are also scarce in India as chickenpox was

not a notifiable disease in India until 200514

and due to the locally-perceived self-limiting and

relatively less severe nature, the disease is under-reported.

Globally, routine and effective vaccination has been identified as a critical approach towards

achieving high and sustained vaccination coverage rates and to strategically deal with the

burden of these four diseases.15

Consequently, the Indian Academy of Pediatrics (IAP) has

recommended the inclusion of a combined measles-mumps-rubella vaccine (MMR) in the

national immunization schedule to provide protection against CRS and also to reduce the

disease burden of measles and mumps.16

In countries with ongoing measles transmission, the

World Health Organization (WHO) recommends a first dose of measles vaccine at 9 months of

age to afford early protection and second dose at 15–18 months with a minimum interval of

one month between the two doses.1 In India, the observed high morbidity and mortality due to

measles has necessitated the administration of the measles vaccine at 9 months of age (by

which time most children will have lost their maternal antibodies to measles)17

followed by

MMR at 15 months of age.18

The IAP also recommends two doses of a varicella vaccine, with

the first dose administered at 15 months of age.18

The second dose may be administered three

months after the first, but is usually given at 4–6 years.18

There is increasing global evidence in

many settings that the high economic burden of varicella would be beneficially alleviated with

the inclusion of varicella vaccine.19-21

GSK’s MMR and varicella vaccines are available in over 100 countries22

and 80 countries,23

respectively. These vaccines are currently not included in the Indian national (government-

provided) immunization program; however, they are available via private practitioners. Based

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on commercially available formulations, a combined MMR-varicella vaccine (MMRV) has been

developed to not only realize the benefits of vaccination against measles, mumps and rubella,

but also to facilitate the potential inclusion of varicella into national immunization programs.24-

27 The new vaccine is as immunogenic as separate MMR and varicella vaccinations.

28-30

This study evaluated the non-inferiority of two different vaccination regimens of the new

MMRV vaccine to the control regimen of separate injections when the vaccines were

administered at 9 and 15 months of age to healthy Indian children.

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Methods

Study design and subjects

This phase IIIb, open, randomized, controlled study (NCT00969436) was conducted at six

tertiary care centers (Supplementary table) in India between November 2009 and February

2011. Healthy subjects aged 9–10 months were randomized (2:2:1) to receive either two doses

of the MMRV vaccine (MMRV/MMRV group) or MMR followed by MMRV (MMR/MMRV group),

or MMR followed by MMR+V (MMR/MMR+V group; control) at 9 and 15 months of age. The

control regimen largely reflects the optimum standard of care available in India under the IAP

recommendations.18

Among the six centers, the center in Bangalore did not enroll subjects according to the

randomization scheme and enrollment ceased at a small number of subjects because the

investigator was transferred (Supplementary table). Subjects were excluded from the study if

they had received any investigational drug/vaccine 30 days before the study vaccine or

immunosuppressants/immune-modifying drugs/blood products six months before the study.

Subjects previously vaccinated against/exposed to measles, mumps, rubella and varicella or

with a history of these diseases could not participate. A history of allergy likely to be aggravated

by any of the vaccine components, neurological disease/seizures, chronic illness or family

history of immunodeficiency, or symptoms of acute illness at the time of enrollment were other

reasons for exclusion. Vaccination was postponed for subjects with a rectal temperature

≥38.0°C/an axillary temperature ≥37.5°C. Subjects were also excluded if they lived in a

household with newborn infants or pregnant women who have not contracted chickenpox

previously or immunocompromised individuals.

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The study adhered to Good Clinical Practice, the Declaration of Helsinki, and all applicable

regulations. The participating centers’ Institutional Ethics Committees/Institutional Review

Boards31

reviewed and approved the protocol. Parents/guardians provided written informed

consent before performing any study-related procedures.

Study Vaccines

All study vaccines: MMR (Priorix™), varicella (Varilrix™) and MMRV (Vammrix™ [same as Priorix-

Tetra™]) were manufactured by GSK, Belgium. The minimum expected potencies for measles,

rubella and varicella were identical between the MMR+V and MMRV vaccines.30

The minimum

expected potency for the mumps content was higher in the MMRV vaccine (≥104.4

median cell

culture infective dose [CCID50]) than in the MMR vaccine (≥103.7

CCID50). The vaccines supplied

in monodose vials contained a freeze-dried pellet which was reconstituted with the diluent

(provided in a pre-filled syringe) before subcutaneous injection into the anterolateral thigh.

Immunogenicity assessment

Blood samples were collected at pre-vaccination and 43 days after doses one and two. Antibody

titers were measured using a commercial enzyme-linked immunosorbent assay (ELISA;

Enzygnost™, Dade Behring, Marburg, Germany) with cut-off values of 150 mIU/mL (measles),

231 U/mL (mumps), and 4 IU/mL (rubella). For varicella, antibody titers were measured using

an immunofluorescence assay (Virgo™, Hemagen Diagnostics, Columbia, MD, USA) (assay cut-

off value of 4 dilution-1

).

Safety/Reactogenicity assessment

Parents/guardians used diary cards to record the occurrence of solicited local symptoms (pain,

redness and swelling at the injection site) for 4 days after each dose and solicited general

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symptoms (fever [axillary temperature ≥37.5°C/rectal temperature ≥38°C], rash/exanthema,

parotid/salivary gland swelling and any suspected signs of meningeal irritation, including febrile

convulsions) for 43 days after each dose. Body temperature was measured daily via the

rectal/axillary route for 15 days after each vaccination. Between days 15 and 42, the presence

of fever was monitored using a temperature-sensitive pad,32

and if fever was suspected,

temperature was accurately measured with a thermometer. There were two follow-up visits

with the investigator at each study center, one vist 42–56 days following each vaccine

administration. During these visits, diary cards were returned to the investigator for

assessment.

Unsolicited symptoms were recorded for 43 days after each dose and the occurrence of serious

adverse events (SAEs) was recorded throughout the study. Intensity of symptoms was graded

on a scale of 0–3. Grade 3 solicited symptoms were defined as: pain: child cried when limb was

moved or a spontaneously painful limb; redness and swelling: injection site surface diameter

>20 mm; fever: axillary temperature >39°C/rectal temperature >39.5°C. Unsolicited symptoms

(including SAEs) were defined as grade 3 when they prevented normal daily activity.

Statistical Analyses

All statistical analyses were performed using SAS version 9.2, and 95% confidence intervals (CI)

were calculated using Proc StatXact 8.1. The sample size was estimated taking into

consideration the co-primary objectives of non-inferiority. Non-inferiority was achieved if the

lower limit of the two-sided standardized asymptotic 95% CI for the difference in

seroconversion rates between the two treatment groups and control group (MMRV/MMRV

minus MMR/MMR+V; MMR/MMRV minus MMR/MMR+V) was ≥-10% for each vaccine antigen,

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43 days post-dose-2. Similarly, the secondary non-inferiority objective was achieved if the lower

limit of the two-sided standardized asymptotic 95% CI for the difference in seroconversion rates

between the MMRV/MMRV group and pooled MMR results from the MMR/MMRV and

MMR/MMR+V groups, 43 days post-dose-1 was ≥-10% for measles, mumps and rubella. A

sample size of 130 evaluable subjects in each treatment group and 65 evaluable subjects in the

control group was planned, which gave a power of at least 93.91% to meet the co-primary

objectives. A central randomization system using a minimization algorithm provided each child

with a unique treatment number. A randomization (2:2:1) blocking scheme ensured that the

balance between treatments was maintained by providing a unique treatment number that

identified the vaccine dose to be administered to the subjects. Furthermore, given different

physical characteristics of the study vaccines and the number of injections between study

groups, the study was conducted in an open manner where in the treatment allocation of

subjects was known to the investigators and the parents/guardians.

Immunogenicity analysis was performed on the according-to-protocol (ATP) cohort which

included all subjects for whom pre- and post-vaccination serology results were available and

who complied with study procedures. Seroconversion rates (defined as the appearance of

antibodies [i.e. antibody concentration/titer ≥cut-off value] in the serum of subjects who were

seronegative before vaccination) and geometric mean titers (GMTs) were calculated with exact

95% CIs for antibodies against each vaccine antigen after each dose. The 95% CIs for the GMTs

were obtained by exponential transformation of the 95% CI for the mean of log-transformed

titer.

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Safety analysis was performed on the total vaccinated cohort (TVC) which included all

vaccinated subjects. Solicited and unsolicited symptoms reported for the subjects during the

respective post-vaccination periods were calculated with exact 95% CIs. All SAEs reported

during the entire conduct of the study were described.

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Results

Demographics

All 450 subjects enrolled in the study were vaccinated and included in the TVC: MMRV/MMRV

(n=180); MMR/MMRV (n=180) and MMR/MMR+V (n=90). Of these, 382 subjects were included

in the ATP cohort for immunogenicity: MMRV/MMRV (n=151); MMR/MMRV (n=156) and

MMR/MMR+V (n=75) (Figure 1). The median age of subjects in the ATP was 9 months (range:

9–10 months); 51.7% were male and all subjects were Indian. No demographic variations were

observed between the study groups (Supplementary table).

Immunogenicity

The proportion of initially seropositive subjects for measles, mumps and rubella was <2.7% in

all three groups. For varicella, 7.4% subjects in the MMRV/MMRV group, 8.3% in the

MMR/MMRV group and 2.7% in the MMR/MMR+V group were initially seropositive. After

dose-1, the seroconversion rates ranged from 87.5%–93.2% for measles, 83.3%–86.1% for

mumps and 98.7%–100% for rubella (Table 1). Post-dose-2 seroconversion rates were 100% for

measles, mumps and rubella and were at least 95.8% for varicella. Across the three vaccination

groups, the observed GMTs to measles, mumps and rubella increased between doses one and

two (Table 1). The co-primary objectives of non-inferiority with respect to seroconversion rates

43 days after dose-2 were achieved for all vaccine antigens, i.e. the lower bounds of the 95% CIs

for the difference in seroconversion rates between groups (MMRV/MMRV vs MMR/MMR+V;

MMR/MMRV vs MMR/MMR+V) was ≥-10%.

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Table 1 Seroconversion rates and Antibody GMTs of the MMRV/MMRV, MMR/MMRV and MMR/MMR+V groups 43 days post-

vaccination (ATP cohort)

Antigen MMRV/MMRV group (N=151) MMR/MMRV group (N=156) MMR/MMR+V group (N=75)

Dose Na

SCb (%)

c (95% CI) GMT

d (95% CI) N

a SC

b (%)

c (95% CI) GMT

d (95% CI) N

a SC

b (%)

c (95% CI) GMT

d (95% CI)

Measles Pre-dose 2 1.3 - 3 1.9 - 2 2.7 -

Post-dose-

1

148 93.2 (87.9; 96.7) 2013.6 (1662.2; 2439.3) 153 88.2 (82.0; 92.9) 1180.4 (963.0; 1446.7) 72 87.5 (77.6; 94.1) 1200.0 (887.9; 1621.8)

Post-dose-

2

149 100 (97.6; 100) 4471.3 (3975.3; 5029.2) 153 100 (97.6; 100) 3358.7 (3017.5; 3738.4) 72 100 (95.0; 100) 2495.0 (2064.5; 3015.2)

Mumps Pre-dose 2 1.3 - 3 1.9 - 2 2.7 -

Post-dose-

1

144 86.1 (79.4; 91.3) 991.9 (819.7; 1200.3) 152 84.2 (77.4; 89.6) 746.6 (628.0; 887.6) 72 83.3 (72.7; 91.9) 775.1 (600.9; 999.7)

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Post-dose-

2

149 100 (97.6; 100) 6428.0 (5774.9; 7154.9) 152 100 (97.6; 100) 10108.5 (9223.9; 11078.0) 72 100 (95.0; 100) 4925.3 (4200.9; 5774.7)

Rubella Pre-dose 1 0.7 - 4 2.6 - 2 1.7 -

Post-dose-

1

149 98.7 (95.2; 99.8) 45.4 (38.3; 53.7) 152 99.3 (96.4; 100) 63.8 (55.9; 72.8) 73 100 (95.1; 100) 62.0 (51.3; 74.9)

Post-dose-

2

150 100 (97.6; 100) 148.4 (136.1; 161.8) 152 100 (97.6; 100) 164.8 (152.1; 178.6) 73 100 (95.1; 100) 173.0 (153.0; 195.6)

Varicella Pre-dose 11 7.4 - 13 8.3 - 2 2.7 -

Post-dose-

1

138 94.2 (88.9; 97.5) 120.5 (90.8; 160.0) 142 2.8 (0.8; 7.1) 2.2 (2.0; 2.4) 72 1.4 (0.0; 7.5) 2.2 (1.8; 2.6)

Post-dose-

2

138 100 (97.4; 100) 5318.5 (4318.7; 6549.8) 143 98.6 (95.0; 99.8) 198.0 (158.2; 247.7) 72 95.8 (88.3; 99.1) 128.0 (91.7; 178.7)

a Number of children initially seronegative with available results

b Seroconversion

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c Percentage of children that seroconverted for each antigen

d Geometric mean titers

The secondary objective of non-inferiority of the MMRV/MMRV group and pooled MMR results from the MMR/MMRV and

MMR/MMR+V groups in terms of seroconversion rates 43-days post-dose-1 for measles, mumps and rubella was also achieved (Table

2).

Table 2 Post-dose-1 seroconversion rates between the MMRV/MMRV group and pooled MMR/MMRV + MMR/MMR+V groups (ATP

cohort)

MMRV MMR

Antibody (MMRV/MMRV group) (Pooled

[MMR/MMRV] +

[MMR/MMR+V]

groups)

Difference in percentage (MMRV

minus MMR)

Na

%b

Na

%b

%c (95% CI)

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MMRV MMR


[MMR/MMRV] +

[MMR/MMR+V]

groups)


minus MMR)

Na

%b

Na

%b

%c (95% CI)

Measles 148 93.2 225 88.0 5.24 (-1.06; 11.13)

Mumps 144 86.1 224 83.9 2.18 (-5.66; 9.42)

Rubella 149 98.7 225 99.6 -0.90 (-4.36; 1.29)

Varicella 138 94.2 - - -

a Number of children initially seronegative with available results

b Percentage of children that seroconverted for each antigen

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c Difference in percentage of children that seroconverted for each antigen between the MMMR/MMRV group and the pooled MMR results from the (MMR/MMRV

+ MMR/MMR+V) groups

Safety and Reactogenicity

During the 43-day post-vaccination period, the occurrence of solicited and unsolicited symptoms ranged between 51.1%–56.1% after

dose-1 and 36.2%–37.3% after dose-2 across the three vaccine groups. During the 4-day post-dose-1 follow-up period, injection site

pain was the most commonly reported solicited local symptom: MMRV/MMRV (11.5%), MMR/MMRV (7%) and MMR/MMR+V (10.7%).

Post-dose-2, injection site symptoms were reported by fewer than 6.5% of subjects (Table 3). Redness was the grade 3 local symptom

reported by 3 subjects (1.9%) in the MMRV/MMRV group, post-dose-2.

Fever was the most commonly reported solicited general symptom in all three vaccine groups during the 43-day post-vaccination

follow-up period after each dose (Table 3). The observed incidence of fever across all vaccine groups decreased between doses one and

two during the 15-day and 43-day post-vaccination follow-up periods (Table 3).

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Table 3 Incidence of solicited local symptoms (during the 4-day) and fever (during the 15-day and 43-day) post-vaccination period

(Total vaccinated cohort)

MMRV/MMRV group MMR/MMRV group MMR/MMR+V group

Dose-1 Na=174;

Dose-2 Na=155

Dose-1 Na=172;

Dose-2 Na=159

Dose-1 Na=84;

Dose-2 Na=79

%b

(95% CI) %b

(95% CI) %b

(95% CI)

Pain Post-dose-1 11.5 (7.2; 17.2) 7.0 (3.7; 11.9) 10.7 (5.0; 19.4)

Post-dose-2 5.8 (2.7; 10.7) 6.3 (3.1; 11.3) 3.8 (0.8; 10.7)

Redness Post-dose-1 8.6 (4.9; 13.8) 4.7 (2.0; 9.0) 3.6 (0.7; 10.1)

Post-dose-2 6.5 (3.1; 11.5) 3.8 (1.4; 8.0) 0.0 (0.0; 4.6)

Swelling Post-dose-1 4.6 (2.0; 8.9) 2.9 (1.0; 6.7) 3.6 (0.7; 10.1)

Post-dose-2 5.8 (2.7; 10.7) 3.8 (1.4; 8.0) 0.0 (0.0; 4.6)

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Fever (15 days

post-dose-1)

Any 32.2 (25.3;39.7) 28.5 (21.9; 35.9) 21.7 (13.4; 32.1)

Grade 3

(>39.5°C)

3.4 (1.3; 7.4) 1.7 (0.4; 5.0) 1.2 (0.0; 6.5)

Related 28.2 (21.6; 35.5) 24.4 (18.2; 31.5) 16.9 (9.5; 26.7)

Medical Advice 6.3 (3.2; 11.0) 7.6 (4.1; 12.6) 2.4 (0.3; 8.4)

Fever (15 days

post-dose-2)

Any 17.4 (11.8;24.3) 13.2 (8.4; 19.5) 15.2 (8.1; 25.0)

Grade

3(>39.5°C)

1.3 (0.2; 4.6) 1.3 (0.2; 4.5) 0.0 (0.0; 4.6)

Related 13.5 (8.6; 20.0) 11.9 (7.4; 18.0) 12.7 (6.2; 22.0)

Medical Advice 3.9 (1.4; 8.2) 1.3 (0.2; 4.5) 1.3 (0.0; 6.9)

Any 43.7 (36.2; 51.4) 40.7 (33.3; 48.4) 32.5 (22.6; 43.7)

Grade 6.3 (3.2; 11.0) 2.9 (1.0; 6.7) 1.2 (0.0; 6.5)

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Fever (43 days

post-dose-1)

3(>39.5°C)

Related 30.5 (23.7; 37.9) 27.9 (21.3; 35.2) 18.1 (10.5; 28.0)

Medical Advice 13.8 (9.0; 19.8) 16.9 (11.6; 23.3) 4.8 (1.3; 11.9)

Fever (43 days

post-dose-2)

Any 26.5 (19.7; 34.1) 23.3 (16.9; 30.6) 27.8 (18.3; 39.1)

Grade

3(>39.5°C)

1.3 (0.2; 4.6) 3.8 (1.4; 8.0) 2.5 (0.3; 8.8)

Related 14.2 (9.1; 20.7) 13.2 (8.4; 19.5) 12.7 (6.2; 22.0)

Medical Advice 4.5 (1.8; 9.1) 5.6 (2.6; 10.5) 7.6 (2.8; 15.8)

a Number of children with at least one documented dose

b Percentage of children reporting the symptom at least once

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An absence of a clear peak in the prevalence of fever during the 43-day period after dose-1 for

all three vaccine groups is depicted in Figure 2(a). Post-dose-2 fever is depicted in Figure 2(b).

Rash occurred in one subject after the first dose of MMRV in the MMRV/MMRV group as

compared to three subjects after the first MMR dose (MMR/MMRV [n=2]; MMR/MMR+V [n=1])

groups). Only one subject developed rash after dose-2 in the MMR/MMRV group. There were

no reports of meningeal irritation, febrile convulsions or parotid gland swelling during the 43-

day period after each vaccine dose.

At least one unsolicited symptom was reported in 20.6% subjects after the first dose of MMRV

in the MMRV/MMRV group and in 21.7% and 20.0% subjects after the first dose of MMR in the

MMR/MMRVand MMR/MMR+V groups, respectively. The most commonly reported symptoms

in each group were: upper respiratory tract infection in the MMRV/MMRV group (n=10; 5.6%);

cough in the MMR/MMRV group (n=10; 5.6%) and nasopharyngitis, rhinitis and cough in the

MMR/MMR+V group (n=6; 6.7% for each symptom). Similarly, at least one unsolicited symptom

was reported in 10.6% subjects after the second dose of MMRV in the MMRV/MMRV group, in

10.0% subjects who received their first dose of MMRV in the MMR/MMRV groups and in 12.2%

subjects following dose-2 of MMR+V in the MMR/MMR+V group. The most commonly reported

symptoms in each group were: rhinitis and cough in the MMRV/MMRV group (n=6; 3.3% for

each symptom) and rhinitis in the MMR/MMRV (n=7; 3.9%) and MMR/MMR+V groups (n=5;

5.6%).

Overall, 18 SAEs occurred in the study. At least one SAE occurred in 13 subjects (MMRV/MMRV

[n=7]; MMR/MMRV [n=6]; MMR/MMR+V [n=0] groups). The most commonly reported SAEs

were lower respiratory tract infection (in two subjects) in the MMRV/MMRV group, and

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gastroenteritis (in three subjects) in the MMR/MMRV group. Other SAEs reported were

gastroenteritis, pneumonitis, wheezing, viral infection, pneumonia, febrile convulsion, upper

respiratory tract inflammation, dehydration and bronchiolitis. All SAEs resolved without

sequelae and were considered unrelated to vaccination.

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Discussion

This non-inferiority study evaluated the immunogenicity and safety of two vaccination regimens

(1) two-dose MMRV/MMRV (2) MMR followed by MMRV compared to a control group (MMR

followed by MMR+V) when administered to healthy Indian children at 9 and 15 months of age.

The co-primary non-inferiority criterion ruling out a 10% difference in seroconversion rates

post-dose-2 of MMRV/MMRV and MMR/MMRV compared to MMR/MMR+V was achieved for

all antigens, indicating that the immune responses elicited by the two vaccination regimens

were non-inferior to those elicited by the control regimen. Although the two-dose

MMRV/MMRV schedule is not included in several immunization programs, this regimen has

been established to be non-inferior to the two-dose MMR+V schedule in separate studies in

Germany and Singapore.30 33

Additionally, on comparing the post-dose-1 responses, one dose of

MMRV in the MMRV/MMRV group elicited non-inferior immune responses against measles,

mumps and rubella compared to pooled results of one dose of MMR in the MMR/MMRV and

MMR/MMR+V groups.

In the three vaccine groups, we observed low baseline seropositivity rates (<2.7%) for measles,

mumps and rubella in subjects at 9 months of age. This finding suggests a possible decline in

circulating maternal antibodies and measles infection by this age which would support 9

months as a suitable age for initial vaccination. However, it should be noted that this finding is

inconsistent with a notable Indian study conducted approximately a decade ago that suggested

the persistence of high circulating maternal antibodies at 9 months of age.11

Additionally, while

lowering the measles vaccination age in low income countries is supported by many,

vaccinating at 9 months or earlier may mean that the immune system has not reached

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optimum maturity to mount an effective response and provide effective long-term protection

against measles or the other diseases with just a single vaccine dose.34 35

The seroconversion

rates for all antigens in the MMRV/MMRV group were consistent with previous observations in

Singaporean children at 9 months of age by Goh et al.33

However, with a first dose of MMR, the

observed post-dose-1 seroconversion rates to measles (MMR/MMRV=88.2%;

MMR/MMR+V=87.5%) and mumps (MMR/MMRV=84.2%; MMR/MMR+V=83.3%) in this study

were somewhat lower than those reported by Schuster et al, following administration of a first

dose of MMR to children aged 11–21 months in Germany (measles: 93.4%; mumps: 93.6%).30

A

contrast in immune responses between the current and German study may be attributed to the

age at vaccination, maturity of the immune system and circulating maternal antibodies. Also,

the higher GMTs oberved to measles in the MMRV/MMRV group compared to the

MMR/MMRV and MMR/MMR+V groups could translate to more effective protection in a highly

endemic measles environment where coverage from a second dose of a measles-containing

vaccine remains variable throughout the country.6 Lower seroconversion rates with other live-

attenuated vaccines (such as the oral polio vaccine and the rotavirus vaccine) have also been

observed in India and South Asia compared to more industrialized settings.36-38

Nevertheless, we observed high seroconversion rates for all vaccine antigens following

administration of second vaccination at 15 months of age, indicating that an early two-dose

immunization strategy when the first dose is administered as early as 9 months elicits a

satisfactory immune response. An interesting observation was the markedly high GMT against

mumps post-dose-2 in the MMR/MMRV (10108.5) group compared to the MMR/MMR+V

(4925.3) and MMRV/MMRV (6428.0) groups. This observation has not been reported previously

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despite the higher mumps antigen content in the MMRV vaccine when compared to the MMR

vaccine. Studies to further evaluate this finding may be needed in the future.

Early administrations of all three vaccination regimens were well-tolerated when administered

to young children at 9 and 15 months of age. Similar differences in solicited general symptoms

have been observed in studies conducted in the Indian subcontinent with other live attenuated

viral vaccines (such as Rotarix™) compared with other countries.37 39

Notably, unlike previous

studies conducted in other countries,28-30 33

this study did not demonstrate any difference in

fever rates between MMRV and MMR when used as a first dose of measles-containing vaccine.

Although this may be related to the epidemiological context in India, which differs from

developed countries, the reason is unclear. In general, the reporting rate of fever was also

lower than that seen in other studies.28-30 33

Again, this may be due to the younger age of

children enrolled, or the presence of maternal antibodies, which may have limited measles

virus replication post-dose-1, resulting in the blunting of immune response and fever response

rates; or cross-cultural/geographical differences in the reporting of symptoms. Further data

may be needed to determine if there is in fact a difference in the reactogenicity profile between

developed and developing countries.

It is possible to eliminate measles from a specific region by sustaining high immunization

coverage as is evident from Latin America, Finland and the United States40-42

; countries such as

Finland have also successfully eliminated mumps and rubella using the MMR vaccine.41

In view

of the ongoing transmission and high mortality risk of measles in India, immunization coverage

of ≥95% for the first and second dose would be required to ensure prevention of measles virus

transmission.43

Currently, the Indian national immunization schedule’s 9 months single dose

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immunization coverage is 74%44

; however, as this represents the average, coverage rates in

some parts of the country may be even lower. Several European countries, where the first

MMR dose is administered to children in the second year of life (12–24 months), continue to

face a relatively low immunization coverage rates resulting in measles and mumps outbreaks,24

as was recently observed even in South Wales.10

An earlier vaccination schedule was

implemented in Germany as a result of such outbreaks, whereby the first dose is now

administered at 11–14 months followed by the second dose at 15–23 months of age.24

This

revised strategy achieved well-documented successful immunization coverage rates,24

and

highlights the importance of early vaccination with increased compliance and subsequently

higher coverage rates.

Conclusion

This study demonstrates that in an Indian setting, the two-dose vaccination regimens of

MMRV/MMRV and MMR/MMRV are non-inferior to the control MMR/MMR+V regimen (i.e.

the local standard of care recommended by the IAP)17

in terms of immunological response.

Both vaccination schedules demonstrated an acceptable safety profile when administered to

healthy Indian children at 9 and 15 months of age. Introduction of the MMRV vaccine may

achieve higher coverage rates in India by increasing compliance for two-dose MMR and

varicella vaccines, and thereby improving the limited success of the MMR vaccination program.

This will not only facilitate effective population protection against measles, but against three

other common childhood viral infectious diseases: mumps, rubella and varicella.

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Trademarks

Vammrix, Priorix-Tetra, Priorix, Varilrix and Rotarix are registered trademarks of

GlaxoSmithKline group of companies.

Virgo is a registered trademark of Hemagen Diagnostics, Columbia, MD, USA.

Enzygnost is a registered trademark of Dade Behring, Marburg, Germany.

Contributors: SL, SB, SC and AB were involved in the recruitment of subjects. SL critically

reviewed the protocol and study report and also provided scientific and medical inputs during

the development of the study report. SB was involved in providing scientific and medical inputs

to the protocol and critically reviewing the protocol. SC coordinated and supervised data

collection at one site and carried out the initial analyses. AB provided critical inputs to the study

report and reviewed the content of the study report. SM and SD conceptualized and designed

the study. SM also supervised data collection at all sites. MP was involved in data analysis and

interpretation. SD and ON provided input to the interpretation of clinical data.

All authors critically reviewed and revised the manuscript during the development and

approved the final version of the manuscript. All authors are guarantors and accept full

responsibility for the work and/or conduct of the study, had access to the data, and controlled

the decision to publish.

Funding: This study was sponsored and funded by GlaxoSmithKline Biologicals SA.

GlaxoSmithKline Biologicals SA was involved in all stages of the study conduct and analysis; and

also took charge of all costs associated with the development and the publishing of the

manuscript.

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Competing interests: All authors have completed the ICMJE uniform disclosure form at

www.icmje.org/coi_disclosure.pdf. SL declares to have received institutional grant (for BVDU

Medical college, Dept. of Pediatrics) and travel support for the meeting from GlaxoSmithKline

group of companies. He also declares to have received fees for lecture at Pedicon 2011. SB

declares that The childs trust medical research foundation received grant from GlaxoSmithKline

group of companies. AB declares to have received institutional grant for conducting this trial

and has pending institutional grants from GlaxoSmithKline group of companies for other

vaccine trials. He also declares to have received support for travel/accomodation while

participating in investigator meetings and renumeration for participating in a meeting on

adjuvants from GlaxoSmithKline group of companies. SM, SD, MP and ON are employees of

GlaxoSmithKline group of companies; SD and ON declare to have stock options. MP declares

that he received payment/fees for review of statistical analysis and reviewing this manuscript

from GlaxoSmithKline group of companies. SC has no conflict of interest. The authors have no

financial relationships relevant to this article to disclose.

Data sharing: Upon authorization or termination of development of this medicine, anonymized

patient-level data underlying this study will be made available to independent researchers,

subject to review by an independent panel, at www.clinicalstudydatarequest.com. Consent for

data sharing was not obtained from the participants, but the presented data are anonymized

and risk of identification is low.

Acknowledgements

The authors thank the study nurses and staff members involved, and the parents and children

who participated in the study. The authors acknowledge Dr. Sonali Palkar for her support in

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conducting the clinical trial and Dipti Phatarpekar for coodinating and supervising data

collection at two study sites. The authors also thank Ashmita Ravishankar for medical writing

and publication coordination (GlaxoSmithKline Vaccines), Jarno Jansen (Keyrus Biopharma for

GlaxoSmithKline Vaccines), Geetha Subramanyam (GlaxoSmithKline Vaccines) and Shruti MP

(GlaxoSmithKline Vaccines) for editorial assistance and publication coordination.

Trial registration: (NCT00969436)

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30 Schuster V, Otto W, Maurer L, et al. Immunogenicity and safety assessments after one and

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healthy children during the second year of life. Pediatr Infect Dis J 2008;27;724–30.

31 Indian clinical trial registry. Available at:

http://ctri.nic.in/Clinicaltrials/showallp.php?mid1=930&EncHid=&userName=CTRI/2009/09

1/000750. Accessed 3 May, 2013.

32 Martyn KK, Urbano MT, Hayes JS, et al. Comparison of axillary, rectal and skin-based

temperature assessment in preschoolers. Nurse Pract 1988;13:31–6.

33 Goh P, Lim FS, Han HH, Willems P. Safety and Immunogenicity of early vaccination with two

doses of tetravalent measles-mumps-rubella-varicella (MMRV) vaccine in healthy children

from 9 months of age. Infection 2007;35:326–33.

34 Aaby P, Martins CL, Garly ML, et al. The optimal age of measles immunisation in low-income

countries: a secondary analysis of the assumptions underlying the current policy. BMJ Open

2012;12:e000761.

35 Gomber S, Arora SK, Das S, et al. Immune response to second dose of MMR vaccine in

Indian children. Indian J Med Res 2011;134:302–6.

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36 Patriarca PA, Wright PF, John TJ. Factors affecting the immunogenicity of oral poliovirus

vaccine in developing countries: review. Rev Infect Dis 1991;13:926–39.

37 Narang A, Bose A, Pandit AN, et al. Immunogenicity, reactogenicity and safety of human

rotavirus vaccine (RIX4414) in Indian infants. Hum Vaccin 2009;5:414–9.

38 Zaman K, Sack DA, Yunus M, et al. Successful co-administration of a human rotavirus and

oral poliovirus vaccines in Bangladesh infants in a 2-dose schedule at 12 and 16 weeks of

age. Vaccine 2009;27:1333–9.

39 Vesikari T, Karvonen A, Puustinen L, et al. Efficacy of RIX4414 live attenuated human

rotavirus vaccine in Finnish infants. Pediatr Infect Dis J 2004;23:937–43.

40 Andrus JK, de Quadros CA, Solorzano CC, et al. Measles and rubella eradication in the

Americas. Vaccine 2011;29S:D91–6.

41 Davidkin I, Kontio M, Paunio M, et al. MMR vaccination and disease elimination: the Finnish

experience. Expert Rev Vaccines 2010;9:1045–53.

42 Mulholland EK. Measles in the United States, 2006. N Engl J Med 2006;355:440–3.

43 World Health Organization. Field guidelines for measles elimination, 2004. Available at:

http://www.measlesrubellainitiative.org/mi-

files/Tools/Guidelines/WPRO/Field_guidelines_measles_elimination.pdf. Accessed 26

September, 2012.

44 World Health Organization. Immunization profile – India. Available at:

http://apps.who.int/immunization_monitoring/en/globalsummary/countryprofileresult.cfm

?C=ind. Accessed 13 November, 2012.

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Figure legends

Figure 1 Subject disposition

Figure 2a Prevalence of fever during the 43-day post-vaccination period after Dose 1


Figure 2b Prevalence of fever during the 43-day post-vaccination period after Dose 2


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292x179mm (300 x 300 DPI)

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149x118mm (300 x 300 DPI)

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Supplementary table

Number of children recruited by study center and demographic characteristics

Name and location of study center in

India

MMRV/MMRV MMR/MMRV

MMR/MMR+V Total

na

%a

Center 1, Pune 37 37 18 92 20.4

Center 2, Pune 53 53 26 132 29.3

Center 3, Bangalore 2 2 2 6 1.3

Center 4, Chennai 24 24 12 60 13.3

Center 5, Kolkata 34 34 17 85 18.9

Center 6, Goa 30 30 15 75 16.7

All 180 180 90 450 100

Demographic characteristics MMRV/MMRV MMR/MMRV MMR/MMR+V Total

Age (months) Mean (standard

deviation)

9 (0.0) 9 (0.11) 9 (0.0) 9 (0.07)

Median (range) 9 (9–9) 9 (8–10) 9 (9–9) 9 (8–10)

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n

% n % n % n %

Gender Female 79 44.4 89 49.2 49 54.4 216 48.3

Male 99 55.6 91 50.8 41 45.6 231 51.7

a number (percentage) of children in a given category

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CONSORT 2010 checklist Page 1

CONSORT 2010 checklist of information to include when reporting a randomised trial*

Section/Topic Item No Checklist item

Reported on page No

Title and abstract

1a Identification as a randomised trial in the title 1

1b Structured summary of trial design, methods, results, and conclusions (for specific guidance see CONSORT for abstracts) 3-4

Introduction

Background and

objectives

2a Scientific background and explanation of rationale 6-8

2b Specific objectives or hypotheses 7-8

Methods

Trial design 3a Description of trial design (such as parallel, factorial) including allocation ratio 9

3b Important changes to methods after trial commencement (such as eligibility criteria), with reasons 9

Participants 4a Eligibility criteria for participants 9

4b Settings and locations where the data were collected 9 and Supp.

table

Interventions 5 The interventions for each group with sufficient details to allow replication, including how and when they were

actually administered

9-10

Outcomes 6a Completely defined pre-specified primary and secondary outcome measures, including how and when they

were assessed

10-11

6b Any changes to trial outcomes after the trial commenced, with reasons Not applicable

Sample size 7a How sample size was determined 12

7b When applicable, explanation of any interim analyses and stopping guidelines Not applicable

Randomisation:

Sequence

generation

8a Method used to generate the random allocation sequence 12

8b Type of randomisation; details of any restriction (such as blocking and block size) 12

Allocation

concealment

mechanism

9 Mechanism used to implement the random allocation sequence (such as sequentially numbered containers),

describing any steps taken to conceal the sequence until interventions were assigned

12

Implementation 10 Who generated the random allocation sequence, who enrolled participants, and who assigned participants to

interventions

9, 11

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Blinding 11a If done, who was blinded after assignment to interventions (for example, participants, care providers, those

assessing outcomes) and how

Not applicable

11b If relevant, description of the similarity of interventions Not applicable

Statistical methods 12a Statistical methods used to compare groups for primary and secondary outcomes 11-13

12b Methods for additional analyses, such as subgroup analyses and adjusted analyses Not applicable

Results

Participant flow (a

diagram is strongly

recommended)

13a For each group, the numbers of participants who were randomly assigned, received intended treatment, and

were analysed for the primary outcome

14/Figure 1

13b For each group, losses and exclusions after randomisation, together with reasons Figure 1

Recruitment 14a Dates defining the periods of recruitment and follow-up Not applicable

14b Why the trial ended or was stopped Not applicable

Baseline data 15 A table showing baseline demographic and clinical characteristics for each group Supp. Table

Numbers analysed 16 For each group, number of participants (denominator) included in each analysis and whether the analysis was

by original assigned groups

14

Outcomes and

estimation

17a For each primary and secondary outcome, results for each group, and the estimated effect size and its

precision (such as 95% confidence interval)

14, 15/Tables

1-3/Figures

2(a) & (b)

17b For binary outcomes, presentation of both absolute and relative effect sizes is recommended Not applicable

Ancillary analyses 18 Results of any other analyses performed, including subgroup analyses and adjusted analyses, distinguishing

pre-specified from exploratory

Not applicable

Harms 19 All important harms or unintended effects in each group (for specific guidance see CONSORT for harms) 15,16

Discussion

Limitations 20 Trial limitations, addressing sources of potential bias, imprecision, and, if relevant, multiplicity of analyses Not applicable

Generalisability 21 Generalisability (external validity, applicability) of the trial findings 17-20

Interpretation 22 Interpretation consistent with results, balancing benefits and harms, and considering other relevant evidence 17-20

Other information

Registration 23 Registration number and name of trial registry 24

Protocol 24 Where the full trial protocol can be accessed, if available Not applicable

Funding 25 Sources of funding and other support (such as supply of drugs), role of funders 21

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*We strongly recommend reading this statement in conjunction with the CONSORT 2010 Explanation and Elaboration for important clarifications on all the items. If relevant, we also

recommend reading CONSORT extensions for cluster randomised trials, non-inferiority and equivalence trials, non-pharmacological treatments, herbal interventions, and pragmatic trials.

Additional extensions are forthcoming: for those and for up to date references relevant to this checklist, see www.consort-statement.org.

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Immunogenicity and safety of early vaccination with two doses of a combined measles-mumps-rubella-varicella

vaccine in healthy Indian children from 9 months of age: a phase III, randomized, non-inferiority trial.

Journal: BMJ Open

Manuscript ID: bmjopen-2014-007202.R1

Article Type: Research

Date Submitted by the Author: 21-May-2015

Complete List of Authors: Lalwani, Sanjay; Bharati Vidyapeeth Medical College, Pediatrics Chatterjee, Sukanta; Medical College Kolkata, Department of Pediatrics Balasubramanian, Sundaram; Kanchi Kamakoti Childs Trust Hospital, Bavdekar, Ashish; KEM Hospital, Mehta, Shailesh; GSK Pharmaceuticals, Datta, Sanjoy; GSK Vaccines, Povey, Michael; GSK Vaccines, Henry, Ouzama; GSK Vaccines,

<b>Primary Subject Heading</b>:

Paediatrics

Secondary Subject Heading: Paediatrics

Keywords: immunogenicity, India, measles-mumps-rubella-varicella vaccine, safety, vaccination schedule


BMJ Open on January 4, 2021 by guest. P

rotected by copyright.http://bm

jopen.bmj.com

/B

MJ O

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Title page 1

Title: Immunogenicity and safety of early vaccination with two doses of a combined measles-2

mumps-rubella-varicella vaccine in healthy Indian children from 9 months of age: a phase III, 3

randomized, non-inferiority trial. 4

Authors: Sanjay Lalwani, Vice Principal, Professor and Head of Departmenta, Sukanta 5

Chatterjee, Professor of Pediatricsb, Sundaram Balasubramanian, Senior Pediatric Consultant

c, 6

Ashish Bavdekar, Associate Professor and Consultant Pediatric Gastroenterologistd, Shailesh 7

Mehta, Area Medical Leader (South Asia)e, Sanjoy Datta, VP, Clinical R&D and Medical Affairs

f, 8

Michael Povey, Biostatisticianf, Ouzama Henry, Clinical Research Development Lead

g 9

Affiliations: aDepartment of Pediatrics, Bharati Vidyapeeth Deemed University, Pune 411043, 10

India 11

bDepartment of Pediatrics, Medical College Kolkata, 88 College street, Kolkata 700073, India 12

cKanchi Kamakoti Childs Trust Hospital, 12-A, Nageswara Road, Nungambakkam, Chennai 13

600034, India 14

dDepartment of Pediatrics, KEM Hospital, 489 Rasta Peth, Sardar Moodliar Road, Pune 411011, 15

India 16

eGSK Pharmaceuticals Ltd., Dr. Annie Besant Road, Worli, Mumbai 400030, India 17

fGSK Vaccines, Avenue Fleming 20, B-1300 Wavre, Belgium 18

gGSK Vaccines, 2301 Renaissance Boulevard, RN 0220, P.O. Box 61540, King of Prussia, PA 19

19406-2772, USA 20

Correspondence to: Sanjay Lalwani 21

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Contact Details: +91 9822051716 22

Fax: +91 20 24364308 23

Email: [email protected] 24

Short title: Combined MMRV vaccine in Indian children 25

Abbreviations 26

ATP–according-to-protocol; CCID50–median cell culture infective dose; CI–confidence interval; 27

CRS–congenital rubella syndrome; ELISA–enzyme-linked immunosorbent assay; GMT–28

geometric mean titer; IAP–Indian Academy of Pediatrics; mIU/mL–milli international unit per 29

milliliter; MMR–combined measles-mumps-rubella vaccine; MMR+V–coadministration of MMR 30

and V; MMRV–combined measles-mumps-rubella-varicella vaccine; pfu–plaque forming units; 31

SAE–serious adverse event; TVC–total vaccinated cohort; V–varicella; VZV–varicella zoster-32

virus; WHO–World Health Organization 33

Keywords: immunogenicity, India, measles-mumps-rubella-varicella vaccine, safety, vaccination 34

schedule 35

Word count: 3521 36

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Abstract 37

Objective: This study (NCT00969436) compared the immunogenicity and safety of measles-38

mumps-rubella (MMR) followed by MMR+varicella (V) vaccines to (1) two doses of combined 39

MMRV and (2) MMR followed by MMRV, in Indian children. 40

Design: Phase III, open, randomized, non-inferiority study. 41

Setting: Six tertiary care hospitals located in India. 42

Participants: Healthy subjects aged 9–10 months not previously vaccinated against/exposed to 43

measles, mumps, rubella and varicella or without a history of these diseases. 44

Interventions: Subjects were randomized (2:2:1) to receive two doses of either MMRV 45

(MMRV/MMRV group) or MMR followed by MMRV (MMR/MMRV group) or MMR followed by 46

MMR+V (MMR/MMR+V, control group) at 9 and 15 months of age. Antibody titers against 47

measles, mumps and rubella were measured using ELISA and against varicella using an 48

immunofluorescence assay. 49

Main outcome measures: To demonstrate non-inferiority of the two vaccination regimens vs. 50

the control in terms of seroconversion rates, defined as a group difference with a lower bound 51

of the 95% confidence interval >-10% for each antigen, 43-days post-dose-2. Parents/guardians 52

recorded solicited local and general symptoms for a 4-day and 43-day period after each vaccine 53

dose, respectively. 54

Results: The seroconversion rates post-dose-1 ranged from 87.5%–93.2% for measles, 83.3%–55

86.1% for mumps and 98.7%–100% for rubella across the three vaccine groups. Seroconversion 56

rates post-dose-2 for measles, mumps and rubella was 100% and at least 95.8% for varicella 57

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across the three vaccine groups. Non-inferiority of MMRV/MMRV and MMR/MMRV to 58

MMR/MMR+V was achieved for all antigens, 43-days post-dose-2. The three vaccination 59

regimens were generally well-tolerated in terms of solicited local and general symptoms. 60

Conclusion: The immune responses elicited by the MMRV/MMRV and MMR/MMRV vaccination 61

regimens were non-inferior to those elicited by the MMR/MMR+V regimen for all antigens. The 62

three vaccination schedules also exhibited an acceptable safety profile in Indian children. 63

Abstract word count: 295/300 64

Trial registration: (NCT00969436)65

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Article Summary 66

• Measles, mumps, rubella (MMR) and varicella are highly infectious vaccine-preventable 67

childhood diseases with high mortality rates in India. 68

• A combined MMR-varicella vaccine may potentially facilitate the control of all four 69

diseases which is as immunogenic as separate MMR and varicella vaccinations. 70

Strengths and limitations of this study 71

• This Indian study provides data for the first time on: 72

• A combined MMRV vaccine in a highly endemic measles setting. 73

• MMRV administered to children at 9 months of age which aligns with the 74

expanded programme of immunization schedule of measles vaccine administered 75

at this age. 76

• Prevaccination serostatus that offers epidemiological indicators on the early 77

disease burden for measles, mumps, rubella and varicella 78

• Limitations of study: The six tertiary care centres where the study was conducted are 79

not representative of the entire Indian population, investigator-bias while reporting AEs 80

due to the the open design of the study, and there were no adjustments made for 81

confounding factors (eg: centers) in the analysis. 82

83

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Introduction 84

Measles, mumps, rubella and varicella are highly infectious vaccine-preventable childhood 85

diseases that continue to pose a significant public health problem in India and beyond.1-4

In 86

2010, global measles mortality was estimated at 139,000 (71,200–447,800) deaths, 47% of 87

which was estimated to have occurred in India.5 In 2011, large measles outbreaks were 88

reported in India (29,339 cases), Pakistan (4,386 cases), Nigeria (18,843 cases) and other 89

countries.6 Although measles elimination was declared in the United States in 2000, the 90

importation of the disease led to the highest number of cases in 2011 (220 cases) since 1996 91

while 159 cases were reported in 2013 by 16 states.7 In the European Union, the Dutch 92

authorites reported 1540 measles cases since May 2013 and in Germany, the reported number 93

of cases is nearly 10 times higher than the total cases in 2012.8 A large number of confirmed 94

cases of measles was also reported in England and Wales between 2012 and 2013, 95

respectively.9 10

Thus, even developed settings may be prone to epidemics if coverage wanes.7-

96

10 97

A dramatic decrease in the worldwide mumps disease burden has been observed since the 98

implementation of large-scale immunization in 1967.2 However, the true incidence in India is 99

difficult to ascertain due to limited baseline epidemiological data.11

100

A study conducted in 2006 revealed that 82.2% children aged between 1 and 5 years, and 101

13.5% aged between 10 and 15 years are susceptible to rubella in the state of Tamil Nadu in 102

southern India.12

Although congenital rubella syndrome (CRS) has been reported in most parts 103

of India, no measures have been undertaken to control this crippling disease and presently, 104

reliable data on CRS in India is limited.13

105

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Epidemiological data on varicella-zoster virus (VZV) are also scarce in India as chickenpox was 106

not a notifiable disease in India until 200514

and due to the locally-perceived self-limiting and 107

relatively less severe nature, the disease is under-reported.

108

Globally, routine and effective vaccination has been identified as a critical approach towards 109

achieving high and sustained vaccination coverage rates and to strategically deal with the 110

burden of these four diseases.15

Consequently, the Indian Academy of Pediatrics (IAP) has 111

recommended the inclusion of a combined measles-mumps-rubella vaccine (MMR) in the 112

national immunization schedule to provide protection against CRS and also to reduce the 113

disease burden of measles and mumps.16

In countries with ongoing measles transmission, the 114

World Health Organization (WHO) recommends a first dose of measles vaccine at 9 months of 115

age to afford early protection and second dose at 15–18 months with a minimum interval of 116

one month between the two doses.1 In India, the observed high morbidity and mortality due to 117

measles has necessitated the administration of the measles vaccine at 9 months of age (by 118

which time most children will have lost their maternal antibodies to measles)17

followed by 119

MMR at 15 months of age.18

The IAP also recommends two doses of a varicella vaccine, with 120

the first dose administered at 15 months of age.18

The second dose may be administered three 121

months after the first, but is usually given at 4–6 years.18

There is increasing global evidence in 122

many settings that the high economic burden of varicella would be beneficially alleviated with 123

the inclusion of varicella vaccine.19-21

124

GSK’s MMR and varicella vaccines are available in over 100 countries22

and 80 countries,23

125

respectively. These vaccines are currently not included in the Indian national (government-126

provided) immunization program; however, they are available via private practitioners. Based 127

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on commercially available formulations, a combined MMR-varicella vaccine (MMRV) has been 128

developed to not only realize the benefits of vaccination against measles, mumps and rubella, 129

but also to facilitate the potential inclusion of varicella into national immunization programs.24-

130

27 The new vaccine is as immunogenic as separate MMR and varicella vaccinations.

28-30 131

This study evaluated the non-inferiority of two different vaccination regimens of the new 132

MMRV vaccine to the control regimen of separate injections when the vaccines were 133

administered at 9 and 15 months of age to healthy Indian children. 134

135

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Methods 136

Study design and subjects 137

This phase IIIb, open, randomized, controlled study (NCT00969436) was conducted at six 138

tertiary care centers (Supplementary table) in India between November 2009 and February 139

2011. The open nature of the study implied that both the investigators and the 140

parents/guardians were aware of the treatment, however the lab personnel generally were 141

unaware of the treatment allocation. Healthy subjects aged 9–10 months were randomized 142

(2:2:1) to receive either two doses of the MMRV vaccine (MMRV/MMRV group) or MMR 143

followed by MMRV (MMR/MMRV group), or MMR followed by MMR+V (MMR/MMR+V group; 144

control) at 9 and 15 months of age. The control regimen largely reflects the optimum standard 145

of care available in India under the IAP recommendations.18

146

Among the six centers, the center in Bangalore did not enroll subjects according to the 147

randomization scheme and enrollment ceased at a small number of subjects because the 148

investigator was transferred (Supplementary table). Subjects were excluded from the study if 149

they had received any investigational drug/vaccine 30 days before the study vaccine or 150

immunosuppressants/immune-modifying drugs/blood products six months before the study. 151

Subjects previously vaccinated against/exposed to measles, mumps, rubella and varicella or 152

with a history of these diseases could not participate. A history of allergy likely to be aggravated 153

by any of the vaccine components, neurological disease/seizures, chronic illness or family 154

history of immunodeficiency, or symptoms of acute illness at the time of enrollment were other 155

reasons for exclusion. Vaccination was postponed for subjects with a rectal temperature 156

≥38.0°C/an axillary temperature ≥37.5°C. Subjects were also excluded if they lived in a 157

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household with newborn infants or pregnant women who have not contracted chickenpox 158

previously or immunocompromised individuals. 159

The study adhered to Good Clinical Practice, the Declaration of Helsinki, and all applicable 160

regulations. The participating centers’ Institutional Ethics Committees/Institutional Review 161

Boards31

reviewed and approved the protocol. Parents/guardians provided written informed 162

consent before performing any study-related procedures. 163

Study Vaccines 164

All study vaccines: MMR (Priorix™), varicella (Varilrix™) and MMRV (Vammrix™ [same as Priorix-165

Tetra™]) were manufactured by GSK, Belgium. The minimum expected potencies for measles, 166

rubella and varicella were identical between the MMR+V and MMRV vaccines.30

The minimum 167

expected potency for the mumps content was higher in the MMRV vaccine (≥104.4

median cell 168

culture infective dose [CCID50]) than in the MMR vaccine (≥103.7

CCID50). The vaccines supplied 169

in monodose vials contained a freeze-dried pellet which was reconstituted with the diluent 170

(provided in a pre-filled syringe) before subcutaneous injection into the anterolateral thigh. 171

Immunogenicity assessment 172

Blood samples were collected at pre-vaccination and 43 days after doses one and two. Antibody 173

titers were measured using a commercial enzyme-linked immunosorbent assay (ELISA; 174

Enzygnost™, Dade Behring, Marburg, Germany) with cut-off values of 150 mIU/mL (measles), 175

231 U/mL (mumps), and 4 IU/mL (rubella). For varicella, antibody titers were measured using 176

an immunofluorescence assay (Virgo™, Hemagen Diagnostics, Columbia, MD, USA) (assay cut-177

off value of 4 dilution-1

). 178

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Safety/Reactogenicity assessment 179

Parents/guardians used diary cards to record the occurrence of solicited local symptoms (pain, 180

redness and swelling at the injection site) for 4 days after each dose and solicited general 181

symptoms (fever [axillary temperature ≥37.5°C/rectal temperature ≥38°C], rash/exanthema, 182

parotid/salivary gland swelling and any suspected signs of meningeal irritation, including febrile 183

convulsions) for 43 days after each dose. Body temperature was measured daily via the 184

rectal/axillary route for 15 days after each vaccination. Between days 15 and 42, the presence 185

of fever was monitored using a temperature-sensitive pad,32

and if fever was suspected, 186

temperature was accurately measured with a thermometer. There were two follow-up visits 187

with the investigator at each study center, one vist 42–56 days following each vaccine 188

administration. During these visits, diary cards were returned to the investigator for 189

assessment. 190

Unsolicited symptoms were recorded for 43 days after each dose and the occurrence of serious 191

adverse events (SAEs) was recorded throughout the study. Intensity of symptoms was graded 192

on a scale of 0–3. Grade 3 solicited symptoms were defined as: pain: child cried when limb was 193

moved or a spontaneously painful limb; redness and swelling: injection site surface diameter 194

>20 mm; fever: axillary temperature >39°C/rectal temperature >39.5°C. Unsolicited symptoms 195

(including SAEs) were defined as grade 3 when they prevented normal daily activity. 196

Statistical Analyses 197

All statistical analyses were performed using SAS version 9.2, and 95% confidence intervals (CI) 198

were calculated using Proc StatXact 8.1. The sample size was estimated taking into 199

consideration the co-primary objectives of non-inferiority. Non-inferiority was achieved if the 200

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lower limit of the two-sided standardized asymptotic 95% CI for the difference in 201

seroconversion rates between the two treatment groups and control group (MMRV/MMRV 202

minus MMR/MMR+V; MMR/MMRV minus MMR/MMR+V) was ≥-10% for each vaccine antigen, 203

43 days post-dose-2. Similarly, the secondary non-inferiority objective was achieved if the lower 204

limit of the two-sided standardized asymptotic 95% CI for the difference in seroconversion rates 205

between the MMRV/MMRV group and pooled MMR results from the MMR/MMRV and 206

MMR/MMR+V groups, 43 days post-dose-1 was ≥-10% for measles, mumps and rubella. 207

Considering that up to 25% of the subjects enrolled could be non-evaluable, a total of 450 208

subjects (180 subjects in each of the treatment groups and 90 subjects in the control group) 209

were to be enrolled in the study. A sample size of 130 evaluable subjects in each treatment 210

group and 65 evaluable subjects in the control group was planned, which gave a power of at 211

least 93.91% with a non-inferiority margin of 10% for all antigens to meet the co-primary 212

objectives. A central randomization system using a minimization algorithm provided each child 213

with a unique treatment number. A randomization (2:2:1) blocking scheme ensured that the 214

balance between treatments was maintained by providing a unique treatment number that 215

identified the vaccine dose to be administered to the subjects. Furthermore, given different 216

physical characteristics of the study vaccines and the number of injections between study 217

groups, the study was conducted in an open manner where in the treatment allocation of 218

subjects was known to the investigators and the parents/guardians. 219

Immunogenicity analysis was performed on the according-to-protocol (ATP) cohort which 220

included all subjects for whom pre- and post-vaccination serology results were available and 221

who complied with study procedures. Seroconversion rates (defined as the appearance of 222

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antibodies [i.e. antibody concentration/titer ≥cut-off value] in the serum of subjects who were 223

seronegative before vaccination) and geometric mean titers (GMTs) were calculated with exact 224

95% CIs for antibodies against each vaccine antigen after each dose. The 95% CIs for the GMTs 225

were obtained by exponential transformation of the 95% CI for the mean of log-transformed 226

titer. 227

Safety analysis was performed on the total vaccinated cohort (TVC) which included all 228

vaccinated subjects. Solicited and unsolicited symptoms reported for the subjects during the 229

respective post-vaccination periods were calculated with exact 95% CIs. All SAEs reported 230

during the entire conduct of the study were described. 231

232

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Results 233

Demographics 234

All 450 subjects enrolled in the study were vaccinated and included in the TVC: MMRV/MMRV 235

(n=180); MMR/MMRV (n=180) and MMR/MMR+V (n=90). Of these, 382 subjects were included 236

in the ATP cohort for immunogenicity: MMRV/MMRV (n=151); MMR/MMRV (n=156) and 237

MMR/MMR+V (n=75) (Figure 1). The median age of subjects in the ATP was 9 months (range: 238

9–10 months); 51.7% were male and all subjects were Indian. No demographic variations were 239

observed between the study groups (Supplementary table). 240

Immunogenicity 241

The proportion of initially seropositive subjects for measles, mumps and rubella was <2.7% in 242

all three groups. For varicella, 7.4% subjects in the MMRV/MMRV group, 8.3% in the 243

MMR/MMRV group and 2.7% in the MMR/MMR+V group were initially seropositive. After 244

dose-1, the seroconversion rates ranged from 87.5%–93.2% for measles, 83.3%–86.1% for 245

mumps and 98.7%–100% for rubella (Table 1). Post-dose-2 seroconversion rates were 100% for 246

measles, mumps and rubella and were at least 95.8% for varicella. Across the three vaccination 247

groups, the observed GMTs to measles, mumps and rubella increased between doses one and 248

two (Table 1). The co-primary objectives of non-inferiority with respect to seroconversion rates 249

43 days after dose-2 were achieved for all vaccine antigens, i.e. the lower bounds of the 95% CIs 250

for the difference in seroconversion rates between groups (MMRV/MMRV vs MMR/MMR+V; 251

MMR/MMRV vs MMR/MMR+V) was ≥-10%. 252

253

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Table 1 Seroconversion rates and Antibody GMTs of the MMRV/MMRV, MMR/MMRV and MMR/MMR+V groups 43 days post-254

vaccination (ATP cohort) 255

Antigen MMRV/MMRV group (N=151) MMR/MMRV group (N=156) MMR/MMR+V group (N=75)

Dose Na

SCb (%)

c (95% CI) GMT

d (95% CI) N

a SC

b (%)

c (95% CI) GMT

d (95% CI) N

a SC

b (%)

c (95% CI) GMT

d (95% CI)

Measles Pre-dose* 2 1.3 - 3 1.9 - 2 2.7 -

Post-dose-

1

148 93.2 (87.9; 96.7) 2013.6 (1662.2; 2439.3) 153 88.2 (82.0; 92.9) 1180.4 (963.0; 1446.7) 72 87.5 (77.6; 94.1) 1200.0 (887.9; 1621.8)

Post-dose-

2

149 100 (97.6; 100) 4471.3 (3975.3; 5029.2) 153 100 (97.6; 100) 3358.7 (3017.5; 3738.4) 72 100 (95.0; 100) 2495.0 (2064.5; 3015.2)

Mumps Pre-dose* 2 1.3 - 3 1.9 - 2 2.7 -

Post-dose-

1

144 86.1 (79.4; 91.3) 991.9 (819.7; 1200.3) 152 84.2 (77.4; 89.6) 746.6 (628.0; 887.6) 72 83.3 (72.7; 91.9) 775.1 (600.9; 999.7)

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Post-dose-

2

149 100 (97.6; 100) 6428.0 (5774.9; 7154.9) 152 100 (97.6; 100) 10108.5 (9223.9; 11078.0) 72 100 (95.0; 100) 4925.3 (4200.9; 5774.7)

Rubella Pre-dose* 1 0.7 - 4 2.6 - 2 1.7 -

Post-dose-

1

149 98.7 (95.2; 99.8) 45.4 (38.3; 53.7) 152 99.3 (96.4; 100) 63.8 (55.9; 72.8) 73 100 (95.1; 100) 62.0 (51.3; 74.9)

Post-dose-

2

150 100 (97.6; 100) 148.4 (136.1; 161.8) 152 100 (97.6; 100) 164.8 (152.1; 178.6) 73 100 (95.1; 100) 173.0 (153.0; 195.6)

Varicella Pre-dose* 11 7.4 - 13 8.3 - 2 2.7 -

Post-dose-

1

138 94.2 (88.9; 97.5) 120.5 (90.8; 160.0) 142 2.8 (0.8; 7.1) 2.2 (2.0; 2.4) 72 1.4 (0.0; 7.5) 2.2 (1.8; 2.6)

Post-dose-

2

138 100 (97.4; 100) 5318.5 (4318.7; 6549.8) 143 98.6 (95.0; 99.8) 198.0 (158.2; 247.7) 72 95.8 (88.3; 99.1) 128.0 (91.7; 178.7)

*Pre-dose values refer to baseline seropositivity rates before vaccination 256

a Number of children initially seronegative with available results 257

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b Seroconversion 258

c Percentage of children that seroconverted for each antigen 259

d Geometric mean titers 260

The secondary objective of non-inferiority of the MMRV/MMRV group and pooled MMR results from the MMR/MMRV and 261

MMR/MMR+V groups in terms of seroconversion rates 43-days post-dose-1 for measles, mumps and rubella was also achieved (Table 262

2). 263

Table 2 Post-dose-1 seroconversion rates between the MMRV/MMRV group and pooled MMR/MMRV + MMR/MMR+V groups (ATP 264

cohort) 265

MMRV MMR


[MMR/MMRV] +

[MMR/MMR+V]

groups)


minus MMR)

Na

%b

Na

%b

%c (95% CI)

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MMRV MMR


[MMR/MMRV] +

[MMR/MMR+V]

groups)


minus MMR)

Na

%b

Na

%b

%c (95% CI)

Measles 148 93.2 225 88.0 5.24 (-1.06; 11.13)

Mumps 144 86.1 224 83.9 2.18 (-5.66; 9.42)

Rubella 149 98.7 225 99.6 -0.90 (-4.36; 1.29)

Varicella 138 94.2 - - -

a Number of children initially seronegative with available results 266

b Percentage of children that seroconverted for each antigen 267

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c Difference in percentage of children that seroconverted for each antigen between the MMMR/MMRV group and the pooled MMR results from the (MMR/MMRV 268

+ MMR/MMR+V) groups 269

Safety and Reactogenicity 270

During the 43-day post-vaccination period, the occurrence of solicited and unsolicited symptoms ranged between 51.1%–56.1% after 271

dose-1 and 36.2%–37.3% after dose-2 across the three vaccine groups. During the 4-day post-dose-1 follow-up period, injection site 272

pain was the most commonly reported solicited local symptom: MMRV/MMRV (11.5%), MMR/MMRV (7%) and MMR/MMR+V (10.7%). 273

Post-dose-2, injection site symptoms were reported by fewer than 6.5% of subjects (Table 3). Redness was the grade 3 local symptom 274

reported by 3 subjects (1.9%) in the MMRV/MMRV group, post-dose-2. 275

Fever was the most commonly reported solicited general symptom in all three vaccine groups during the 43-day post-vaccination 276

follow-up period after each dose (Table 3). The observed incidence of fever across all vaccine groups decreased between doses one and 277

two during the 15-day and 43-day post-vaccination follow-up periods (Table 3). 278

279

280

281

282

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Table 3 Incidence of solicited local symptoms (during the 4-day) and fever (during the 15-day and 43-day) post-vaccination period 283

(Total vaccinated cohort) 284

MMRV/MMRV group MMR/MMRV group MMR/MMR+V group

Dose-1 Na=174;

Dose-2 Na=155

Dose-1 Na=172;

Dose-2 Na=159

Dose-1 Na=84;

Dose-2 Na=79

%b

(95% CI) %b

(95% CI) %b

(95% CI)

Pain Post-dose-1 11.5 (7.2; 17.2) 7.0 (3.7; 11.9) 10.7 (5.0; 19.4)

Post-dose-2 5.8 (2.7; 10.7) 6.3 (3.1; 11.3) 3.8 (0.8; 10.7)

Redness Post-dose-1 8.6 (4.9; 13.8) 4.7 (2.0; 9.0) 3.6 (0.7; 10.1)

Post-dose-2 6.5 (3.1; 11.5) 3.8 (1.4; 8.0) 0.0 (0.0; 4.6)

Swelling Post-dose-1 4.6 (2.0; 8.9) 2.9 (1.0; 6.7) 3.6 (0.7; 10.1)

Post-dose-2 5.8 (2.7; 10.7) 3.8 (1.4; 8.0) 0.0 (0.0; 4.6)

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Fever (15 days

post-dose-1)

Any 32.2 (25.3;39.7) 28.5 (21.9; 35.9) 21.7 (13.4; 32.1)

Grade 3

(>39.5°C)

3.4 (1.3; 7.4) 1.7 (0.4; 5.0) 1.2 (0.0; 6.5)

Related 28.2 (21.6; 35.5) 24.4 (18.2; 31.5) 16.9 (9.5; 26.7)

Medical Advice 6.3 (3.2; 11.0) 7.6 (4.1; 12.6) 2.4 (0.3; 8.4)

Fever (15 days

post-dose-2)

Any 17.4 (11.8;24.3) 13.2 (8.4; 19.5) 15.2 (8.1; 25.0)

Grade

3(>39.5°C)

1.3 (0.2; 4.6) 1.3 (0.2; 4.5) 0.0 (0.0; 4.6)

Related 13.5 (8.6; 20.0) 11.9 (7.4; 18.0) 12.7 (6.2; 22.0)

Medical Advice 3.9 (1.4; 8.2) 1.3 (0.2; 4.5) 1.3 (0.0; 6.9)

Any 43.7 (36.2; 51.4) 40.7 (33.3; 48.4) 32.5 (22.6; 43.7)

Grade 6.3 (3.2; 11.0) 2.9 (1.0; 6.7) 1.2 (0.0; 6.5)

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Fever (43 days

post-dose-1)

3(>39.5°C)

Related 30.5 (23.7; 37.9) 27.9 (21.3; 35.2) 18.1 (10.5; 28.0)

Medical Advice 13.8 (9.0; 19.8) 16.9 (11.6; 23.3) 4.8 (1.3; 11.9)

Fever (43 days

post-dose-2)

Any 26.5 (19.7; 34.1) 23.3 (16.9; 30.6) 27.8 (18.3; 39.1)

Grade

3(>39.5°C)

1.3 (0.2; 4.6) 3.8 (1.4; 8.0) 2.5 (0.3; 8.8)

Related 14.2 (9.1; 20.7) 13.2 (8.4; 19.5) 12.7 (6.2; 22.0)

Medical Advice 4.5 (1.8; 9.1) 5.6 (2.6; 10.5) 7.6 (2.8; 15.8)

a Number of children with at least one documented dose 285

b Percentage of children reporting the symptom at least once 286

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An absence of a clear peak in the prevalence of fever during the 43-day period after dose-1 for 287

all three vaccine groups is depicted in Figure 2(a). Post-dose-2 fever is depicted in Figure 2(b). 288

Rash occurred in one subject after the first dose of MMRV in the MMRV/MMRV group as 289

compared to three subjects after the first MMR dose (MMR/MMRV [n=2]; MMR/MMR+V [n=1]) 290

groups). Only one subject developed rash after dose-2 in the MMR/MMRV group. There were 291

no reports of meningeal irritation, febrile convulsions or parotid gland swelling during the 43-292

day period after each vaccine dose. 293

At least one unsolicited symptom was reported in 20.6% subjects after the first dose of MMRV 294

in the MMRV/MMRV group and in 21.7% and 20.0% subjects after the first dose of MMR in the 295

MMR/MMRVand MMR/MMR+V groups, respectively. The most commonly reported symptoms 296

in each group were: upper respiratory tract infection in the MMRV/MMRV group (n=10; 5.6%); 297

cough in the MMR/MMRV group (n=10; 5.6%) and nasopharyngitis, rhinitis and cough in the 298

MMR/MMR+V group (n=6; 6.7% for each symptom). Similarly, at least one unsolicited symptom 299

was reported in 10.6% subjects after the second dose of MMRV in the MMRV/MMRV group, in 300

10.0% subjects who received their first dose of MMRV in the MMR/MMRV groups and in 12.2% 301

subjects following dose-2 of MMR+V in the MMR/MMR+V group. The most commonly reported 302

symptoms in each group were: rhinitis and cough in the MMRV/MMRV group (n=6; 3.3% for 303

each symptom) and rhinitis in the MMR/MMRV (n=7; 3.9%) and MMR/MMR+V groups (n=5; 304

5.6%). 305

Overall, 18 SAEs occurred in the study. At least one SAE occurred in 13 subjects (MMRV/MMRV 306

[n=7]; MMR/MMRV [n=6]; MMR/MMR+V [n=0] groups). The most commonly reported SAEs 307

were lower respiratory tract infection (in two subjects) in the MMRV/MMRV group, and 308

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gastroenteritis (in three subjects) in the MMR/MMRV group. Other SAEs reported were 309

gastroenteritis, pneumonitis, wheezing, viral infection, pneumonia, febrile convulsion, upper 310

respiratory tract inflammation, dehydration and bronchiolitis. All SAEs resolved without 311

sequelae and were considered unrelated to vaccination. 312

313

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Discussion 314

This non-inferiority study evaluated the immunogenicity and safety of two vaccination regimens 315

(1) two-dose MMRV/MMRV (2) MMR followed by MMRV compared to a control group (MMR 316

followed by MMR+V) when administered to healthy Indian children at 9 and 15 months of age. 317

The co-primary non-inferiority criterion ruling out a 10% difference in seroconversion rates 318

post-dose-2 of MMRV/MMRV and MMR/MMRV compared to MMR/MMR+V was achieved for 319

all antigens, indicating that the immune responses elicited by the two vaccination regimens 320

were non-inferior to those elicited by the control regimen. Although the two-dose 321

MMRV/MMRV schedule is not included in several immunization programs, this regimen has 322

been established to be non-inferior to the two-dose MMR+V schedule in separate studies in 323

Germany and Singapore.30 33

Additionally, on comparing the post-dose-1 responses, one dose of 324

MMRV in the MMRV/MMRV group elicited non-inferior immune responses against measles, 325

mumps and rubella compared to pooled results of one dose of MMR in the MMR/MMRV and 326

MMR/MMR+V groups. 327

In the three vaccine groups, we observed low baseline seropositivity rates (<2.7%) for measles, 328

mumps and rubella in subjects at 9 months of age. This finding suggests a possible decline in 329

circulating maternal antibodies and measles infection by this age which would support 9 330

months as a suitable age for initial vaccination. However, it should be noted that this finding is 331

inconsistent with a notable Indian study conducted approximately a decade ago that suggested 332

the persistence of high circulating maternal antibodies at 9 months of age with baseline 333

seropositivity rates of 15% for measles and 20% each for mumps and rubella.11

Additionally, 334

while lowering the measles vaccination age in low income countries is supported by many, 335

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vaccinating at 9 months or earlier may mean that the immune system has not reached 336

optimum maturity to mount an effective response and provide effective long-term protection 337

against measles or the other diseases with just a single vaccine dose.34 35

The seroconversion 338

rates for all antigens in the MMRV/MMRV group were consistent with previous observations in 339

Singaporean children at 9 months of age by Goh et al.33

However, with a first dose of MMR, the 340

observed post-dose-1 seroconversion rates to measles (MMR/MMRV=88.2%; 341

MMR/MMR+V=87.5%) and mumps (MMR/MMRV=84.2%; MMR/MMR+V=83.3%) in this study 342

were somewhat lower than those reported by Schuster et al, following administration of a first 343

dose of MMR to children aged 11–21 months in Germany (measles: 93.4%; mumps: 93.6%).30

A 344

contrast in immune responses between the current and German study may be attributed to the 345

age at vaccination, maturity of the immune system and circulating maternal antibodies. Also, 346

the higher GMTs oberved to measles in the MMRV/MMRV group compared to the 347

MMR/MMRV and MMR/MMR+V groups could translate to more effective protection in a highly 348

endemic measles environment where coverage from a second dose of a measles-containing 349

vaccine remains variable throughout the country.6 Lower seroconversion rates with other live-350

attenuated vaccines (such as the oral polio vaccine and the rotavirus vaccine) have also been 351

observed in India and South Asia compared to more industrialized settings.36-38

352

Nevertheless, we observed high seroconversion rates for all vaccine antigens following 353

administration of second vaccination at 15 months of age, indicating that an early two-dose 354

immunization strategy when the first dose is administered as early as 9 months elicits a 355

satisfactory immune response. An interesting observation was the markedly high GMT against 356

mumps post-dose-2 in the MMR/MMRV (10108.5) group compared to the MMR/MMR+V 357

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(4925.3) and MMRV/MMRV (6428.0) groups. This observation has not been reported previously 358

despite the higher mumps antigen content in the MMRV vaccine when compared to the MMR 359

vaccine and studies that evaluate this finding may be needed in the future. 360

Early administrations of all three vaccination regimens were well-tolerated when administered 361

to young children at 9 and 15 months of age. Similar differences in solicited general symptoms 362

have been observed in studies conducted in the Indian subcontinent with other live attenuated 363

viral vaccines (such as Rotarix™) compared with other countries.37 39

Notably, unlike previous 364

studies conducted in other countries,28-30 33

this study did not demonstrate any difference in 365

fever rates between MMRV and MMR when used as a first dose of measles-containing vaccine. 366

Although this may be related to the epidemiological context in India, which differs from 367

developed countries, the reason is unclear. In general, the reporting rate of fever was also 368

lower than that seen in other studies.28-30 33

Again, this may be due to the younger age of 369

children enrolled, or the presence of maternal antibodies, which may have limited measles 370

virus replication post-dose-1, resulting in the blunting of immune response and fever response 371

rates; or cross-cultural/geographical differences in the reporting of symptoms. Further data 372

may be needed to determine if there is in fact a difference in the reactogenicity profile between 373

developed and developing countries. 374

It is possible to eliminate measles from a specific region by sustaining high immunization 375

coverage as is evident from Latin America, Finland and the United States40-42

; countries such as 376

Finland have also successfully eliminated mumps and rubella using the MMR vaccine.41

In view 377

of the ongoing transmission and high mortality risk of measles in India, immunization coverage 378

of ≥95% for the first and second dose would be required to ensure prevention of measles virus 379

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transmission.43

Currently, the Indian national immunization schedule’s 9 months single dose 380

immunization coverage is 74%44

; however, as this represents the average, coverage rates in 381

some parts of the country may be even lower. Several European countries, where the first 382

MMR dose is administered to children in the second year of life (12–24 months), continue to 383

face a relatively low immunization coverage rates resulting in measles and mumps outbreaks,24

384

as was recently observed even in South Wales.10

An earlier vaccination schedule was 385

implemented in Germany as a result of such outbreaks, whereby the first dose is now 386

administered at 11–14 months followed by the second dose at 15–23 months of age.24

This 387

revised strategy achieved well-documented successful immunization coverage rates,24

and 388

highlights the importance of early vaccination with increased compliance and subsequently 389

higher coverage rates. 390

A few limitations of the study that should be considered: (1) the six tertiary care centers where 391

the study was conducted are not representative of the entire Indian population, (2) 392

investigator-bias while reporting AEs due to the the open design of the study, and (3) there 393

were no adjustments made for confounding factors (eg: centers) in the analysis.

394

Conclusion 395

This study demonstrates that in an Indian setting, the two-dose vaccination regimens of 396

MMRV/MMRV and MMR/MMRV are non-inferior to the control MMR/MMR+V regimen (i.e. 397

the local standard of care recommended by the IAP)17

in terms of immunological response. 398

Both vaccination schedules demonstrated an acceptable safety profile when administered to 399

healthy Indian children at 9 and 15 months of age. Introduction of the MMRV vaccine may not 400

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only facilitate effective population protection against measles, but against three other common 401

childhood viral infectious diseases: mumps, rubella and varicella.

402

403

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Trademarks 404

Vammrix, Priorix-Tetra, Priorix, Varilrix and Rotarix are registered trademarks of 405

GlaxoSmithKline group of companies. 406

Virgo is a registered trademark of Hemagen Diagnostics, Columbia, MD, USA. 407

Enzygnost is a registered trademark of Dade Behring, Marburg, Germany. 408

Contributors: SL, SB, SC and AB were involved in the recruitment of subjects. SL critically 409

reviewed the protocol and study report and also provided scientific and medical inputs during 410

the development of the study report. SB was involved in providing scientific and medical inputs 411

to the protocol and critically reviewing the protocol. SC coordinated and supervised data 412

collection at one site and carried out the initial analyses. AB provided critical inputs to the study 413

report and reviewed the content of the study report. SM and SD conceptualized and designed 414

the study. SM also supervised data collection at all sites. MP was involved in data analysis and 415

interpretation. SD and OH provided input to the interpretation of clinical data. 416

All authors critically reviewed and revised the manuscript during the development and 417

approved the final version of the manuscript. All authors are guarantors and accept full 418

responsibility for the work and/or conduct of the study, had access to the data, and controlled 419

the decision to publish. 420

Funding: This study was sponsored and funded by GlaxoSmithKline Biologicals SA. 421

GlaxoSmithKline Biologicals SA was involved in all stages of the study conduct and analysis; and 422

also took charge of all costs associated with the development and the publishing of the 423

manuscript. 424

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Competing interests: All authors have completed the ICMJE uniform disclosure form at 425

www.icmje.org/coi_disclosure.pdf. SL declares to have received institutional grant (for BVDU 426

Medical college, Dept. of Pediatrics) and travel support for the meeting from GlaxoSmithKline 427

group of companies. He also declares to have received fees for lecture at Pedicon 2011. SB 428

declares that The childs trust medical research foundation received grant from GlaxoSmithKline 429

group of companies. AB declares to have received institutional grant for conducting this trial 430

and has pending institutional grants from GlaxoSmithKline group of companies for other 431

vaccine trials. He also declares to have received support for travel/accomodation while 432

participating in investigator meetings and renumeration for participating in a meeting on 433

adjuvants from GlaxoSmithKline group of companies. SM, SD, MP and OH are employees of 434

GlaxoSmithKline group of companies; SD and OH declare to have stock options. MP declares 435

that he received payment/fees for review of statistical analysis and reviewing this manuscript 436

from GlaxoSmithKline group of companies. SC has no conflict of interest. The authors have no 437

financial relationships relevant to this article to disclose. 438

Data sharing: Upon authorization or termination of development of this medicine, anonymized 439

patient-level data underlying this study will be made available to independent researchers, 440

subject to review by an independent panel, at www.clinicalstudydatarequest.com. Consent for 441

data sharing was not obtained from the participants, but the presented data are anonymized 442

and risk of identification is low. 443

Acknowledgements 444

The authors thank the study nurses and staff members involved, and the parents and children 445

who participated in the study. The authors acknowledge Dr. Sonali Palkar for her support in 446

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conducting the clinical trial and Dipti Phatarpekar for coodinating and supervising data 447

collection at two study sites. The authors also thank Ashmita Ravishankar for medical writing 448

and publication coordination (GlaxoSmithKline Vaccines), Jarno Jansen (Keyrus Biopharma for 449

GlaxoSmithKline Vaccines), Geetha Subramanyam (GlaxoSmithKline Vaccines) and Shruti MP 450

(GlaxoSmithKline Vaccines) for editorial assistance and publication coordination. 451

Trial registration: (NCT00969436) 452

453

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41 Davidkin I, Kontio M, Paunio M, et al. MMR vaccination and disease elimination: the Finnish 549

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Figure legends 560

Figure 1 Subject disposition 561

Figure 2a Prevalence of fever during the 43-day post-vaccination period after Dose 1 562


Figure 2b Prevalence of fever during the 43-day post-vaccination period after Dose 2 564


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Subject disposition

292x179mm (300 x 300 DPI)

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Prevalence of fever during the 43-day post-vaccination period after Dose 1 (Total vaccinated cohort) 149x118mm (300 x 300 DPI)

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Prevalence of fever during the 43-day post-vaccination period after Dose 2 (Total vaccinated cohort) 148x117mm (300 x 300 DPI)

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14 Nov 2014

Supplementary table

Number of children recruited by study center and demographic characteristics

Name and location of study center in

India

MMRV/MMRV MMR/MMRV

MMR/MMR+V Total

na

%a

Center 1, Pune 37 37 18 92 20.4

Center 2, Pune 53 53 26 132 29.3

Center 3, Bangalore 2 2 2 6 1.3

Center 4, Chennai 24 24 12 60 13.3

Center 5, Kolkata 34 34 17 85 18.9

Center 6, Goa 30 30 15 75 16.7

All 180 180 90 450 100

Demographic characteristics MMRV/MMRV MMR/MMRV MMR/MMR+V Total

Age (months) Mean (standard

deviation)

9 (0.0) 9 (0.11) 9 (0.0) 9 (0.07)

Median (range) 9 (9–9) 9 (8–10) 9 (9–9) 9 (8–10)

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14 Nov 2014

n

% n % n % n %

Gender Female 79 44.4 89 49.2 49 54.4 216 48.3

Male 99 55.6 91 50.8 41 45.6 231 51.7

a number (percentage) of children in a given category

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14 Nov 2014

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CONSORT 2010 checklist of information to include when reporting a randomised trial*

Section/Topic Item No Checklist item

Reported on page No

Title and abstract

1a Identification as a randomised trial in the title 1

1b Structured summary of trial design, methods, results, and conclusions (for specific guidance see CONSORT for abstracts) 3-4

Introduction

Background and

objectives

2a Scientific background and explanation of rationale 6-8

2b Specific objectives or hypotheses 7-8

Methods

Trial design 3a Description of trial design (such as parallel, factorial) including allocation ratio 9

3b Important changes to methods after trial commencement (such as eligibility criteria), with reasons 9

Participants 4a Eligibility criteria for participants 9

4b Settings and locations where the data were collected 9 and Supp.

table

Interventions 5 The interventions for each group with sufficient details to allow replication, including how and when they were

actually administered

9-10

Outcomes 6a Completely defined pre-specified primary and secondary outcome measures, including how and when they

were assessed

10-11

6b Any changes to trial outcomes after the trial commenced, with reasons Not applicable

Sample size 7a How sample size was determined 12

7b When applicable, explanation of any interim analyses and stopping guidelines Not applicable

Randomisation:

Sequence

generation

8a Method used to generate the random allocation sequence 12

8b Type of randomisation; details of any restriction (such as blocking and block size) 12

Allocation

concealment

mechanism

9 Mechanism used to implement the random allocation sequence (such as sequentially numbered containers),

describing any steps taken to conceal the sequence until interventions were assigned

12

Implementation 10 Who generated the random allocation sequence, who enrolled participants, and who assigned participants to

interventions

9, 11

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Blinding 11a If done, who was blinded after assignment to interventions (for example, participants, care providers, those

assessing outcomes) and how

Not applicable

11b If relevant, description of the similarity of interventions Not applicable

Statistical methods 12a Statistical methods used to compare groups for primary and secondary outcomes 11-13

12b Methods for additional analyses, such as subgroup analyses and adjusted analyses Not applicable

Results

Participant flow (a

diagram is strongly

recommended)

13a For each group, the numbers of participants who were randomly assigned, received intended treatment, and

were analysed for the primary outcome

14/Figure 1

13b For each group, losses and exclusions after randomisation, together with reasons Figure 1

Recruitment 14a Dates defining the periods of recruitment and follow-up Not applicable

14b Why the trial ended or was stopped Not applicable

Baseline data 15 A table showing baseline demographic and clinical characteristics for each group Supp. Table

Numbers analysed 16 For each group, number of participants (denominator) included in each analysis and whether the analysis was

by original assigned groups

14

Outcomes and

estimation

17a For each primary and secondary outcome, results for each group, and the estimated effect size and its

precision (such as 95% confidence interval)

14-23/Tables

1-3/Figures

2(a) & (b)

17b For binary outcomes, presentation of both absolute and relative effect sizes is recommended Not applicable

Ancillary analyses 18 Results of any other analyses performed, including subgroup analyses and adjusted analyses, distinguishing

pre-specified from exploratory

Not applicable

Harms 19 All important harms or unintended effects in each group (for specific guidance see CONSORT for harms) 23

Discussion

Limitations 20 Trial limitations, addressing sources of potential bias, imprecision, and, if relevant, multiplicity of analyses Not applicable

Generalisability 21 Generalisability (external validity, applicability) of the trial findings 25-29

Interpretation 22 Interpretation consistent with results, balancing benefits and harms, and considering other relevant evidence 25-29

Other information

Registration 23 Registration number and name of trial registry 32

Protocol 24 Where the full trial protocol can be accessed, if available Not applicable

Funding 25 Sources of funding and other support (such as supply of drugs), role of funders 30

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*We strongly recommend reading this statement in conjunction with the CONSORT 2010 Explanation and Elaboration for important clarifications on all the items. If relevant, we also

recommend reading CONSORT extensions for cluster randomised trials, non-inferiority and equivalence trials, non-pharmacological treatments, herbal interventions, and pragmatic trials.

Additional extensions are forthcoming: for those and for up to date references relevant to this checklist, see www.consort-statement.org.

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